Indications for TIPS

Question:  A 54 year old male has diuretic-refractory ascites, ie. he can’t tolerate maximum doses of furosemide and spironolactone; he developed severe hyponatremia (Na 121).  He asks you if TIPS is a good idea for his tense ascites.  All of the following are important considerations except one. 

A. check an ultrasound with doppler to be sure there is no portal vein thrombosis (PVT)

B. get a cardiac echo to be sure there is no pulmonary hypertension

C. check a renal ultrasound to be sure the problem isn’t in his kidneys

D. inquire about the patient’s history of hepatic encephalopathy


Answer: Diuretic-refractory ascites is a common indication for TIPS placement.  By creating a conduit between the hepatic vein and portal vein, you decrease sinusoidal pressure enough to alleviate the hydrostatic forces that produce ascites.  However, it’s not always a good idea to send your patient for TIPS.

An ultrasound with doppler is important; a PVT or hepatocellular carcinoma are contraindications.  Also, if the bilirubin is high (>3-4) the conduit will divert too much blood and the liver will fail because of a steal phenomenon. 

Being sure there is no right-sided heart failure and no pulmonary hypertension will help you ensure that the heart will tolerate the anticipated increase in preload.  Of course, a history of moderate or severe hepatic encephalopathy suggests poor mental status outcomes.  Don’t worry too much about the kidneys following TIPS placement; if anything, they may experience increased perfusion when the cardiac preload increases.

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